This blog is based on an article that will appear in a forthcoming book by Rabbi Pinchas Cohen, A Practical Guide to the Laws of Family Purity

What is OCD?

Obsessive compulsive disorder (OCD) is a mental health disorder that affects about 1-3% of adults and is considered one of the most debilitating mental disorders of our era. It is also a misunderstood and commonly misdiagnosed disorder. OCD is time-consuming and causes significant distress and impairment in a person’s quality of life, relationships, work, and religious practice. Though the ritualistic behavior of an individual with OCD may sometimes look strange, people with OCD are not “crazy,” in fact, they are generally insightful, creative, intelligent and kind people. OCD is known to affect elements of a person’s life that they hold dear to them, creating havoc in areas that once added value and purpose. This is one of the cruelest parts of the disorder.

Obsessions are defined as recurrent and persistent thoughts, images, urges or doubts that are experienced as intrusive or unwanted and generally trigger intense feelings such as anxiety, distress, or disgust.

Compulsions are excessive, repetitive behaviors or “mental acts” that an individual feels driven to perform in an attempt to neutralize the obsessions, decrease their distress, or to prevent a dreaded event and to diminish responsibility for its occurrence.

OCD is often referred to as “the doubting disease.” Doubt fuels the fire for OCD as sufferers feel the need to control everything in their lives; they feel their distress and worry will continue unless they carry out a certain behavior. The compulsions, also referred to as safety-seeking behaviors, are a desperate attempt to gain certainty. Rituals usually provide temporary relief and are therefore extremely reinforcing. In fact, the solution becomes the problem – that is, the checking, demands for certainty and reassurance actually increase distress, further doubt, and preoccupation. Ironically, behaviors aimed at reducing threat and gaining control inevitably lead to just the opposite – a loss of control over one’s life.

Religious Obsessions (Scrupulosity)

Religious obsessions, referred to as scrupulosity, is when a person is overly concerned that something they thought or did might be a sin or violation of a religious or moral doctrine. Common compulsions related to mikvah include: avoidance of looking at undergarments for fear of seeing a questionable stain, or alternatively, compulsively checking undergarments for staining; not touching anything (e.g. faucet, wall) after bathing for fear there may be soapy residue on the faucet which could be a chatzitzah; calling a halachic authority to ask questions following immersion and/or calling back to add information or clarify the question/answer; spending hours preparing for mikvah (often focusing on hair, nails or dry skin) as well as re-checking body parts for chatzizot before or after immersion; seeking reassurance from a halachic authority/husband/self; narrowing one’s focus of attention to monitor thoughts and memory of the preparation process (which paradoxically reduces a woman’s confidence in her memory, which in turn, leads to further checking behaviors); re-immersion in the mikvah; and efforts to suppress or distract oneself from intrusive thoughts. Avoidance of mikvah through use of pills to delay menstruation is also commonly seen in women with OCD.

How can scrupulosity be distinguished from normal religious practice?

One who is meticulous in keeping mitzvot or accepts stringencies, chumrot, upon herself can be distinguished from a person suffering from OCD by keeping the following characteristics in mind. Religious obsessions are: 1. recurrent and persistent. 2. experienced as intrusive or unwanted. 3. trigger intense feelings such as anxiety, distress, discomfort, or disgust. 4. seem to signal danger which the person can cause or prevent. Compulsions, as opposed to observance of mitzvot, are intended to neutralize distress via – rituals, reassurance seeking, mental arguments, thought suppression, living up to impossible criteria, or avoidance.

Unlike normal religious practice, scrupulous behavior is generally stereotyped and inflexible. The OCD sufferer often disregards religious laws, focusing excessively on one area of religious practice while other, more important areas may be completely ignored. The behavior exceeds what is required by halacha or minhag and is typically inconsistent with that of the rest of the community.

Thought patterns in OCD

Cognitive biases or distortions are faulty thought patterns that skew the way we perceive our thoughts, ourselves and the world around us. The difference between a normal intrusive thought and an obsessional thought lies both in the meaning/interpretation that individuals with OCD attach to it, and their response.

Let us look at an example of what the OCD process may look like in which a “normal” thought or doubt is interpreted and responded to in a way that fuels OCD. Included in brackets are common “cognitive biases” characteristic of OCD sufferers.

Situation: A woman immerses in the mikvah.

Thought – “What if I forgot a step of the preparation process and my immersion was not kosher?”

Non-OCD interpretation – It is just a thought, it may or may not be true but no one can have 100% certainty and so I will move on. I have done what is halachically required, that is good enough, even if it doesn’t feel right.

OCD interpretation of the thought – If I have this thought it probably means that I forgot a part of the preparation process (overestimation of the likelihood of danger i.e. sinning). Having the thought is morally equivalent to not immersing properly (thought-action fusion). I need to be absolutely certain that I immersed properly (intolerance of uncertainty/ambiguity). I should “feel” tahor after the mikvah and I do not. This is further evidence that my immersion was not kosher (Emotional Reasoning). This Mitzvah is entirely my responsibility. If I have relations with my husband we would be sinning and punished with kareit (inflated sense of responsibility). I need to act to prevent us from sinning (need for control). I must pay close attention to the doubts I am having (excessive attentional bias on monitoring intrusive thoughts). My immersion was surely invalid (reduced attention to real events-i.e. mikvah attendant told me I was tahor). Maybe I am not really G-d fearing (catastrophic interpretation of thought).

Feeling-Anxiety/distress.

Possible compulsions-Re-check body for possible chatzitot, re-check memory of preparation process, ask mikvah attendent to re-immerse.

This is a scenario in which the woman’s “solution” (compulsion) to a her perceived “problem” (doubt) actual becomes the problem itself. A woman who re-immerses in the mikvah may feel temporary relief, however, by doing so she strengthens the belief that her immersion was indeed unkosher and she does not learn that the anxiety would eventually have gone down even without re-immersing. Likewise, when a woman doubts whether her bedikah cloth is clean (“problem”) and she performs numerous bedikot to be certain that there is no blood (“solution”), this actually leads to consequent doubt and she may even cause bleeding. This is the case with most compulsions. They provide short-lived relief but only add gas to the flame.

Treatment

Scrupulosity responds to the same treatments as those used with other forms of OCD. The most effective evidence-based treatments for OCD are medication and a type of Cognitive Behavioral Therapy (CBT) called Exposure and Response Prevention (ERP). An OCD sufferer can never completely get rid of unwanted thoughts. However, with treatment s/he may be able to experience intrusive thoughts without responding as if the content is necessarily true, important, or reflective of a person’s true nature. The thoughts will eventually decrease in frequency, intensity and be less distressing. The majority of people (around 70%) will benefit from therapy, medicine, or a combination of the two. Treatment for scrupulosity may also include consultation with a halachic authority.

With regard to mikvah, women with OCD often experience extreme distress anticipating mikvah night and spend hours preparing for immersion. While preparing for the mikvah a woman in treatment would be encouraged to move through the preparation process and immerse even if she is not 100 percent certain that she has done everything correctly, with the aim of decreasing her preparation time to a total of approximately 45 min to 1.5 hours. The goal is not to try to accomplish the same amount of work that she has been doing in a less amount of time, but rather to consider it “good enough” and to move on after she has spent the suggested amount of time.

The approach of ERP is in line with the teachings of the Ramban who states that, “Regarding the laws of chatzitzah, it is improper for a person to be overly stringent and to search for doubts to invalidate the tevilah…for if one takes this approach there is no end to the matter. Rather, after she washed her hair and combed it with a comb and soaped and washed her whole body in warm water…and has performed tevillah…she should not entertain doubts which have no end or termination (Hilchot Niddah 9:25).”  The Chachamin understood that it is unnecessary and impossible to be absolutely sure that a woman will not sin; she will need to take the reasonable risks that other people in her community are taking.

It is also crucial to remember that in these cases the problem is not due to lack of knowledge of halachot or lack of will to keep mitzvot. The problem is anxiety-based, not religious. A woman will not overcome OCD by learning more halachot or getting an answer to her question from a halachic authority.

If you or someone you love suffers from OCD, it is important to see a licensed therapist that is specialty-trained in treating OCD. They will give you the tools and knowledge needed to enable you to break out of the “OCD prison” and regain mental freedom.

Dr. Natalie Gar is a psychologist who specializes in Cognitive Behavioral Therapy (CBT) for OCD and anxiety disorders. She runs a private practice in Jerusalem and Gush Etzion.